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CVS Exam

Routine & Script

Id like to perform a CVS exam .This will involve me examining your hands, feet face & pulses. Is that ok?

General:Comfortable at rest, Anxiety, pallor, distress, breathlessness, sweating, oedema, obesity, thin

Feet:Temp, Colour, Sweaty/Dry, Pitting oedemaHands:Temp, Colour, Sweaty/Dry, Dorsalis pedis

Nails:Koilonychia, Splinter haemorrhage, ClubbingWrists:Radial pulse (30 secs)Im going to touch you face is that ok?

Face:Colour, Temporal artery

Could you pull down your eyelids like this(Demonstrate for them)Eyes: Colour of sclera, Xanthelasma, Corneal ArcusCould you open your mouth & lift your tongueMouth: Colour, Angular Stomatis, Beefy Tongue, SublingualNeck: Carotid pulses (one at a time), JVP

Ausculation: valvesIs it ok to place the heal of my hand on the mid line of your chest? (demo)Palpation: Sternal heave = increased effort & increased heart sizeApex beat shift

Percussion: to map out the heart if you think it may have enlarged (surface antomy of the heart at bottom of

page)Pulses:

HistoryRecent Dyspnoea, Chest Pain, Oedema, Palpitations, Tiredness, Nausea, Syncope, Claudication,Medical Diabetes, Rheumatic fever, Rheumatic heart disease, Marfans, Family history (hyperten

heart disease, stroke, hyperlipidemia)Social Exercise, Smoking, Alcohol, Diet

Observation

General Comfortable at rest, Anxiety, pallor, distress, breathlessness, sweating, oedema, obesity,

thin

Feet Pitting oedema If indentation still evident after 10 sec, test again higher up. Congested/Rsided heart failure, vena cava, liver, kidney disorder, DVT, hypoalbuminia

(osmotic pressure), low protein diet

Temp and colour Same as in hands

Hands Temp Hot + Pink = carbon dioxide retention

peripheral vasodilatation

Cold + blue = poss heart problem.

Blood flow, peripheral cyanosioccurs on hands/feet, not mucous membrane. Causes: Raynauds,

atheroma (plaque in artery walls)

Warm + blue = poss respiratory prob, perfusion, occurs on lips +

tongue Causes: Central cyanosis arterial hypoxaemia, pulmonarydisease

Sweaty hyperthyroidism

Colour Pale Raynouds syndrome gangrene

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Yellow nicotine

Blue peripheral cyanosis

Nails Koilonychia Iron deficiency, possibly blood loss

Splinter

hemorrhage

Small emboli under nail. Causes: Manual worker, infective endocarditis

Clubbing Fluctuation nail/bed angle, nail curvature, ST bulkHeart Subacute bact endocarditis, Cyanotic congenital heart disease

Lung Bronchial carcinoma, Fibrosing alveolitis

GI Cirrhosis, Ulcerative colitis, Crohns disease

Idiopathic

Capillary bedrefill test

If takes > 2 secs. Causes dehydration, peripheral vascular disease,

raynauds, shock

Face Colour Pallor Oxygenated Hb in skinBlue O2 in blood, Cyanosis

Malar flush Rosy cheeks

Eyes Xanthelasma yellow blisters around eye, cholesterol, hyperlipedemia, poss liverdysfunction

Conjunctiva Pale AnemiaBlue cyanosis

Bleeding capillaries NSAID, hypertension

Corneal Arcus Silvery white line around eye (> 50) in young cholesterol

Mouth Breathing patterns normal/panting. Shape (Kyphoscoliosis?)Angular stomatitis Crack at corners, dont heal well Anemia, malabsorbtion, iron/folic A,

Vit B

Tongue Colour Big beefy smooth red sore Glossitis, iron/folic acid/Vit B,Pale Anemia

Brown/dry Mouth breathers, dehydrated , smokers

Blue central cyanosis

Anaemia (+ pain from papillae atrophy)Creamy curd like Candida Albicus (Corticosteroids med)

Sub-lingual Engorged sublingual veins Portal hypertension

Auscultation

Mitral area L 5th ICS, mid-clavicularline

lub soundGood place for abnormal 3rd and 4th sounds and mitral

murmurs

Tricusped area R 5th ICS, sternal border Aortic regurgitation heard here

Aortic area R 2nd ICS, 1 cm from

sternum

Aortic stenosis, murmurs

Pulmonary area L 2nd ICS, 1cm from

sternum

dub sound

pulmonary valve murmurPercussion

Heart should be roughly fist size. Tends to enlarge laterally, not medially.

Palpation

Parasternal heave Heel of hand over

parasternal area

Heave present if hand felt lifting with each systole.

Causes: Right ventricle enlargement (hardworking hearts get

bigger), hypertension, Aortic stenosis

Apex beat shift Palpate MCL 5th ICS Normally should be 3-4cm in diameter

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(Pt rolls 45 degree to

their left. start at MCL& move to Mid

Axillary Line

Deviation Causes (enlargement of L ventricle) pectus

excavatum/sinus inversion. Cardiomegaly/mediastinal shift (leslikely)

Absent death/ obesity/pericarditis/emphysema (or other

COPD)/sinus inversus/pericardial or pleural effusion

Apex beat quality Forceful beat CO2Thrill (vibrations) palpable murmursGallop (3rd heart sound) possible L ventricular dysfunction

Uncoordinated MI

Pulses

Head/neck Carotid Only one at a time!

Found between the anterior border of the SCM above thehyoid bone and lateral to the thyroid cartilage.

Temporal Over temple just anterior to ear If blocked may lead to blindness in elderly

UEX Brachial In cubital fossa, just medial to biceps tendon

Radial Anterior surface of distal radius.Important for checking radiofemoral delay

LEX Femoral Mid-inguinal point, halfway between the pubic symphysis an

ASIS

Get consent first!

Popliteal Posterior knee, easiest to find with knee flexed

Dorsalis pedis between 1st and 2nd met (lat to EHL tendon)

Tibialis posterior 2 cm inferior and 2 cm posterior to the medial malleolus

JVP Patient at 45, turn head

R and observe alongSCM

Look for double dip 2-4cm above sternal angle

Hepatojugular reflex press abdomen, will raise pressure

Bradycardia < 60bpm aortic stenosis, anorexia, beta blockers>100 bpm Anxiety, hyperthyroidism, vagus nerve lesion

Radiofemoral

delay

If femoral weak possible aortic aneurism

Blood pressure

Normal Between 90/60 120/80

High >160/95 anxiety, temp, no cause, drug, disease, aortic coarctation,

NSAID

Low

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Upper border = 3rd costal cartilage on right of sternum to 2nd intercostal space on the left side of

sternum.

Right margin the heart descends from the 3rd costal cartilage to 6th costal cartilage.

Left margin from 2nd intercostal space to Apex at the midclavicular line in the 5th intercostal space.

Summary: Right = 3CC to 6CC Left = 2IC to 5IC*CC = costal cartilage IC = Intercostal Space